29.8 Clinical Care for Emergencies

Question 1

Triggers for Anaphylaxis

Answer 1

(1) Drugs (Antibiotics, NSAIDs, ANYDRUG)
(2) Food (nuts, shellfish, soy, eggs)
(3) Additives (sulfites)
(4) Toxins (insect stings, venom)
(5) Chemicals (contrast dye, latex)

Question 2

Signs and Symptoms
(1) Classic Presentation
(a)Pruritis
(b)Flushing
(c)Urticaria
(2) Progression
(a)Throat fullness (lump sensation)
(b)Anxiety
(c)Chest tightness, SOB, Lightheadedness
(3) Severe reaction
(a)Loss of consciousness
(b)Cardiorespiratory arrest
(4) Signs and symptoms begin within 60 mins of exposure
(5) The faster the onset, the more severe the reaction
(6) After resolution of symptoms, patients at risk for recurrence
(a)21% will have a reoccurrence within 12 hours after resolution of the first episode

Answer 2

Anaphylaxis

Question 3

With suspected anaphylaxis, the single most important step in treatment is the rapid administration of

Answer 3

Epinepherine

Question 4

Management steps for anaphylaxis

Answer 4

(a)REMOVE AGENT (no gastric lavage)
(b) Primary Survey (adjuncts, advance airway options, cricothyrotomy); airway challenges
(c)IV/IO, O2, monitor, lines
(d) EPINEPHRINE 0.5 mg IM is the preferred route
(e)Bolus with fluids (NS or LR)
(f)Secondary Survey
(g) MEDEVAC/MEDAVICE

Question 5

Second line therapies for Anaphylaxis

Answer 5

• Methylprednisolone (Solumedrol) 125mg IM/IV daily x 2 days
• Diphenhydramine (Benadryl) - 25-50 mg IV
• Nebulized albuterol 5mg nebulized or via inhaler every 15-30 minutes as needed for bronchospasm

Question 6

Food allergy characteristics

Answer 6

(a) Obtain detailed history, typically mild
(b) Swelling and itching of lips, mouth, throat, epinephrine if airway symptoms develop
(c)Nausea, vomiting, diarrhea, abdominal cramps Cutaneous symptoms
(d) Antihistamines and trial elimination diets are gaining popularity as treatment modalities

Question 7

Drug Allergy sx

Answer 7

(a) Usually within the first or second week
(b) Pruritus
(c) Urticaria
(d) Fever
(e) Erythema
(f)Angioedema
(g) Stevens-Johnson (SJS) or toxic epidermal necrolysis (TEN)

Question 8

(1)Nonspecific group of injuries that describes injury to the respiratory tract including upper airway, tracheobronchial tree and pulmonary parenchyma
(2)Caused by heat, smoke or chemicals
(3)Fire is the leading cause of injuries.

Answer 8

Smoke Inhalation injury

Question 9

Smoke inhalation causes what kind of injury to the upper airway

Answer 9

Thermal Injury

Question 10

What in smoke inhalation causes injury to tracheobronchial tree

Answer 10

Chemicals in the smoke

Question 11

How does smoke inhalation affect lung parenchyma

Answer 11

Injury to the lung tissue, usually a delayed process.

Question 12

What is systemic toxicity

Answer 12

caused by breathing toxic substances. Two most relevant gases are carbon monoxide and hydrogen cyanide

Question 13

Which substance describes the following:
1)Frequent cause of death and most common complication after inhalationinjury
2)Colorless and odorless gas
3)Affinity for hemoglobin 260 times greater than oxygen
4)Of note, O2 sat cannot screen for it as it does not differentiate between oxyhemoglobin and carboxyhemoglobin

Answer 13

Carbon Monoxide (CO)

Question 14

Which substance describes the following:
1)Gaseous form is colorless and odor of bitter almonds
2)Difficult to screen for and treatment should be considered in all inhalation injuries
3)Treatment should be initiated patients who are at risk and who display altered mental status, cardiac arrest or signs of heart failure

Answer 14

Hydrogen cyanide

Question 15

Hallmark sx for Upper Airway Smoke inhalation injury

Answer 15

Dyspnea

Question 16

Hallmark sx for Lower Airway Smoke inhalation injury

Answer 16

Productive cough

Question 17

Clinical findings include
(1 soot around nares,
(2 carbonaceous sputum,
(3 obvious burns to neck and face,(4 stridor,
(5 drooling,
(6 dysphonia
(7 dyspnea

Answer 17

Upper Airway Smoke inhalation injury

Question 18

Clinical findings include
1)tachypnea,
2)decreased breath sounds,
3)adventitious lungs sounds
4)accessory muscle use.
5) productive cough

Answer 18

Lower respiratory tract and parenchyma smoke inhalation injury

Question 19

Lab studies for smoke inhalation

Answer 19

1)CBC,
2)Chemistry panel,
3)Lactate and
4)Any available toxicological screens (CO/ABG/VBG)

Question 20

Rads for smoke inhalation

Answer 20

Chest X-Ray
1)Typically obtained early in the course.
- May be normal initially however, it is useful as a baseline.

Question 21

Why would you get an EKG for smoke inhalation

Answer 21

1)Useful in any patient being evaluated for toxicological purposes.
2)CO poisoning can lead to myocardial ischemia

Question 22

Treatment of Smoke inhalation

Answer 22

(1)First step is rescue from source and limit exposure time
(a)ABC’s and ATLS protocols with frequent re-assessment
(b)For critically ill patients secure the airway and initiate prompt MEDEVAC as needed
(c)Signs of thermal injury to the airway - intubation is indicated
(d)Significant burns (>40%) even with an airway that seems intact might require prophylactic intubation if capability exist due to impending edema and airway compromise
(e)Provide 100% O2 by tight fitting mask or via endotracheal tube.
(f)IV Fluids for burns
(g)Inhaled bronchodilators for bronchospasm
(h)Prevent hypothermia

Question 23

Medications for smoke inhalation

Answer 23

Albuterol
- Acute treatment: 1 to 2 inhalations every 2 hours for the first 4 hours; additional inhalations may be necessary every 4 to 6 hours as needed if inadequate relief
- Maintenance (in combination with corticosteroid therapy): 1 to 2 inhalations every 4 to 6 hours as needed (maximum: 8 inhalations daily)

Question 24

When should hyperbaric oxygen be given for smoke inhalation

Answer 24

Hyperbaric oxygen for significant CO toxicity in consultation with specialist

Question 25

What is the following injury:
(1) Occurs with injury/necrosis to the muscle fiber.
(2)Contents of muscle fibers (CK/myoglobin) leak into circulation and results in the complications
(3)Leakage of extracellular calcium ions into the intracellular space. Interactionleads to interaction of actin and myosin that ends in muscle destruction.
(4)Large quantities of potassium, myoglobin and CK leak into circulation andlead to the complications.
(5)If large amount of muscle is damaged the myoglobin released canprecipitate in the kidneys and cause renal damage and obstruction.

Answer 25

Rhabdomyolysis

Question 26

The following can cause what injury
Trauma or muscle compression (consider in patients that have been founddown for prolonged periods)
(a) Trauma,
(b) Crush injury,
(c) Prolonged restraints or immobilization,
(d) Compartment syndrome,
(e) Electrical injuries

Answer 26

Rhabdomyolysis

Question 27

The following can cause what injury
(a) Individual is not conditioned (New recruits)
(b) Hot humid conditions
(c) Impaired sweating (heat stroke)
(d) Seizures and delirium tremens
(e) Methamphetamine and cocaine use (exertional and non-exertional)

Answer 27

Exertional Rhabdomyolysis

Question 28

The following can cause what injury
(a) Coma induced by drugs (opioids, alcohol that lead to a prolonged “down” period)
(b) Medications (statins though they more commonly cause myalgias.
(c) Toxins (snake venom & CO)

Answer 28

Non exertional Rhabdomyolysis

Question 29

Symptoms and Exam
(1)Muscle tenderness
(2)Edema
(3)Muscle weakness
(4)Dark urine (*Coca Cola urine)
(5)Altered mental status may occur from underlying etiology

Answer 29

Rhabdomyolysis

Question 30

Labs for Rhabdomyolysis

Answer 30

(1)Elevation in CK (Hallmark) typically fivefold increase from normal
(2) Urinalysis dipstick positive for blood however no red blood cells on microscopic exam.(test does not differentiate between myoglobin and hemoglobin)
(3)Electrolyte abnormalities (*Hyperkalemia)
(4)EKG to evaluate electrolyte abnormalities (Hyperkalemia (causes peaked T waves))

Question 31

Treatment of Rhabdomyolysis

Answer 31

(1)Large volume IV fluid resuscitation (1.5L/hr) to maintain 2ml/kg/hr urine output
(2) If there is no altered mental status and they are maintaining the 2ml/kg/hr urine output then it is reasonable to keep them on your platform and monitor
(3) If there is any altered mental status, temp > 105, or unresponsive to IV fluids then need to immediate MEDEVAC
(4)Some patients may go have progressive renal failure and require hemodialysis